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"4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED No # (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Add res�2��^�—�a � � City !s t Size PM Owner's Name 1+ �-• T Address Phone ' 'i Contractor .0-C-0 "Z Address License No, Phone r _ TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT'[] w DESTRUCTION El g.3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE: OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' E'1 Public ❑ Other ❑ Delta Depth of Grout Seal `Type of Grout R I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter __ Sealing Material (top 501 �. A� � Depth t Filler Material (Below 50'i t `'� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTIO (No septic system permitted if public sewer is 4available within 200 feet.I ornmercial ?Other Installation will serve: Residence GI E . Number of living units: Number of bedrooms Character of soil to a depthpt 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ -"..,_�,s _ � Method of Disposal----- - Distance to nearest: Well Foundation Property Line T - LEACHING LINE CI No. & Length of lines Total length/size l :- FILTER BED a" ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS LlDistance to nearest: Well Foundation Property Line DISPOSAL PONDS `: C" ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.":Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican t call for all required ins coons. Co late drawing on reverse side. • �}-, y 7 Signed X Title: _�%t`.// �/1� Date: FOR EPARTMENT USE ONLY kDate 0- Ar a Application Accepted by j Pit or Grout Inspection by Date Final inspection by Date Q / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental.Health Permit/Services 1601 E. Haz6lton Ave., P.O. Box 2009, Stk., CA 95201 CKC _3FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT'NO. INFO + EH 13-24iREV.1/95) r� 110 -247 7^-369 EH 14-IB i N